FLORIDA CENTER FOR HEALTH INFORMATION AND POLICY ANALYSIS AGENCY FOR HEALTH CARE ADMINISTRATION

Florida Electronic Prescribing Annual Report for 2014 FLORIDA CENTER FOR HEALTH INFORMATION AND POLICY ANALYSIS AGENCY FOR HEALTH CARE ADMINISTRATION JANUARY 2015

Acknowledgements The Agency for Health Care Administration gratefully acknowledges the following organizations and individuals who contributed electronic prescribing metrics to this report. Surescripts Emdeon erx Network Magellan Michael Alsentzer, Florida Medicaid Pharmacy Services Agency for Health Care Administration 2

Executive Summary Introduction The 2014 Florida Electronic Prescribing Report provides an updated annual assessment of the status of electronic prescribing (e-prescribing) in Florida. It presents a review of Agency for Health Care Administration (Agency) activities to promote e-prescribing; highlights of state and national e-prescribing initiatives; Florida e-prescribing metrics; and action steps to promote adoption of e-prescribing coordinated with other Agency health information technology initiatives. This report is mandated in Section 408.0611, Florida Statutes, which directs the Agency to disseminate information on e-prescribing and promote its adoption. E-prescribing enables the electronic transmission of prescriptions as well as access to a patient s medication history by prescribing physicians at the point of care. Properly used, it improves prescription accuracy, increases patient safety, and medication adherence. Accessing patients medication history through e-prescribing systems enables physicians to be aware of other medications ordered and to better coordinate patient care with other treating physicians. E- prescribing adoption continues to increase because it produces benefits and cost savings for all participants including physicians, pharmacies, and patients. Electronic Prescribing Highlights in 2014 In 2014, the Centers for Medicare and Medicaid Services (CMS) and the Agency continued making Medicare and Medicaid incentive payments respectively for the meaningful use of certified electronic health records (EHRs) under the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. The HITECH Act provisions established meaningful use rules which include e-prescribing in the core set of required measures for eligible professionals to qualify for incentive payments. CMS issued the stage 2 requirements for meaningful use in August 2012, which raised the bar for e-prescribing to 50% of prescriptions (unless excluded) starting in 2014. The Agency engaged in outreach to pharmacies regarding its Direct Messaging service of the Florida Health Information Exchange (Florida HIE). Pharmacies will be able to use Direct Messaging to securely communicate health information with physicians and other providers. National and state e-prescribing organizations, payers, and professional associations continued to produce educational materials to encourage greater use of e- prescribing. Together, these developments have resulted in continued growth in the adoption of e- prescribing. Agency e-prescribing Outreach Strategies With the assistance of data provided by national e-prescribing organizations, the Agency produces a quarterly dashboard of e-prescribing metrics showing trends, and a comparison of Florida rates to national e-prescribing rates. In addition, the Agency works in close collaboration with representatives of Florida s regional extension centers (RECs) which have the mission of assisting health care providers achieve meaningful use. In 2014, a survey of pharmacists was conducted by Florida International University (FIU) to assist the Agency in understanding factors that would 3

encourage further adoption of e-prescribing. The survey found high rates of adoption by pharmacies and e-prescribers but the e-prescribing of controlled substances was reported to occur infrequently. Metrics The Agency has developed and published a set of key metrics for tracking e-prescribing adoption rates in Florida. E-prescribing metrics can be viewed on the Agency s website at http://fhin.net/eprescribing/dashboard/index.shtml. These metrics enable the Agency to gauge progress in the state and in comparison with national rates. Metrics collected and reported quarterly include: Counts of new and refill e-prescriptions; E-prescribing percent increase quarterly and annually; E-prescriptions per e-prescriber; and Medicaid medication record requests per total requests. The amount of e-prescribing relative to the estimated number of all prescriptions that could have been e-prescribed is the e-prescribing rate. The annual e-prescribing rate as of the end of the third quarter of 2014 was 56.1 percent, up from the annual e-prescribing rates of 51.6 percent in 2013, 41.3 percent in 2012, 27.1 percent in 2011, 18.4 percent in 2010, 11.3 percent in 2009, 4.3 percent in 2008, and 1.6 percent in 2007. Medication record requests are requests where physicians used e-prescribing tools to access information such as eligibility, benefits, or medication history. The number of Medicaid medication record requests averaged 551,813 per month during 2011, 956,313 during 2012, and 1,194,841 per month during 2013. The number of Medicaid medication record requests averaged 1,369,518 from January through September 2014, showing a 15 percent increase from 2013. In 2013, Florida s e-prescribing activity ranked 27 th among states as reported by Surescripts, down from its 23 rd ranking in the prior year. The Agency set a goal of achieving an e-prescribing rate of 60% in 2014. By the end of Q3 2014, the e-prescribing rate was 56.1%. Although the rate of increase in e-prescribing was slower in 2014, the inclusion of e-prescribing in the meaningful use of EHRs is expected to stimulate greater use of e-prescribing and related clinical applications. Florida Electronic Prescribing Clearinghouse The Agency s Florida Electronic Prescribing Clearinghouse provides users a single point of access for e-prescribing information. It is designed to meet the requirements of Section 408.0611 Florida Statutes, and provides information on developments and trends in e-prescribing. The overall goal is to promote the adoption of e-prescribing and improve the quality and effectiveness of e-prescribing in the state. Current and previous Florida e-prescribing annual reports are posted on the website as well as quarterly metrics on the status of e-prescribing adoption in Florida. The annual report provides up-to-date information on the benefits of e-prescribing derived from reports in the health service research literature. Information about nationally certified products for the EHR Incentive Program, including e-prescribing tools, can be found at the companion website, Medicaid Electronic Health Record Incentive Program. 4

Health Information Exchange Coordinating Committee In 2007, the Agency established the Health Information Exchange Coordinating Committee (HIECC) under the State Consumer Health Information and Policy Advisory Council (Advisory Council) authorized in Section 408.05 (8) Florida Statutes. The HIECC includes representatives of hospitals, long-term care, medical associations, regional health information organizations, clinicians, health plans, rural health, economic development organizations, consumer organizations and a representative of the Florida Pharmacy Association. Action steps for the Committee to further accelerate the adoption of e-prescribing in Florida are detailed in Section 2.9. of this report. 5

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Table of Contents SECTION 1. STATUS OF ELECTRONIC PRESCRIBING... 8 1.1. WHAT IS ELECTRONIC PRESCRIBING?... 8 1.2. ELECTRONIC PRESCRIBING HIGHLIGHTS IN 2014... 9 1.3. ELECTRONIC PRESCRIBING METRICS AND TRENDS... 10 1.4 SURVEY OF FLORIDA PHARMACISTS ON ELECTRONIC PRESCRIBING... 15 SECTION 2. ELECTRONIC PRESCRIBING ADOPTION ACTIVITIES... 19 2.1. FLORIDA ELECTRONIC PRESCRIBING CLEARINGHOUSE... 19 2.2. MEANINGFUL USE INCENTIVES FOR ELECTRONIC PRESCRIBING... 19 2.3. MEDICARE INCENTIVES FOR ELECTRONIC PRESCRIBING... 20 2.4. ELECTRONIC PRESCRIBING OF CONTROLLED SUBSTANCES... 21 2.5. PHARMACY E-HEALTH INFORMATION TECHNOLOGY COLLABORATIVE... 21 2.6. ELECTRONIC PRESCRIBING STANDARDS AND CERTIFICATION BODIES... 22 2.7. OUTREACH TO PHARMACIES... 23 2.8. HEALTH INFORMATION EXCHANGE COORDINATING COMMITTEE... 23 2.9. ACTION STEPS... 23 7

Section 1. Status of Electronic Prescribing In 2007, the Florida Legislature passed HB 1155, which created Section 408.0611, Florida Statutes, which states that the Agency for Health Care Administration (Agency) is to collaborate with stakeholders to create an electronic prescribing (e-prescribing) clearinghouse and coordinate with private sector e-prescribing initiatives. The Legislature also directed the Agency to prepare an annual report on the progress of e-prescribing implementation in Florida. The first annual report was published in January 2008. Previous reports are available on the web at: www.floridahealthfinder.gov/researchers/studies-reports.aspx This Florida Electronic Prescribing Annual Report provides a general assessment of the status of e- prescribing in Florida in 2014. It reports highlights of e-prescribing developments that include increased e-prescribing requirements established as part of the Stage 2 requirements for the meaningful use of electronic health records (EHRs). The report provides monthly metrics on e- prescribing in Florida as available through 2014, based on metrics provided by national e- prescribing networks and Florida Medicaid. This report also includes the finding of a survey of Florida pharmacists conducted in 2014 regarding pharmacist experiences in the use of e- prescribing. It concludes with a review of Agency strategies to promote e-prescribing in 2015. 1.1. What is Electronic Prescribing? Electronic prescribing (e-prescribing) makes use of health information technology that enables the electronic transmission of prescriptions and access to medication history by prescribing physicians at the point of care. It improves prescription accuracy, increases patient safety, and reduces costs primarily because of the critical health care information it makes available to the physician or other prescribing practitioner. A major benefit of the electronic transfer of the prescription is the elimination of errors caused by miscommunication of the handwritten paper prescription. E- prescribing can reduce opportunities for fraud and abuse that currently occur due to a lack of secure prescription delivery to the pharmacy. E-prescribing also creates a more traceable trail for auditing purposes. An article published in U.S. Pharmacist in 2013 provides a compilation of benefits and problems of electronic prescribing (e-prescribing) that have been documented in the research literature. Benefits include: Enhanced patient safety through avoidable errors associated with a written prescription (i.e., illegible handwriting) and lack of systematic checks that e-prescribing systems can provide; Reduced drug costs from alerts such as formulary decision support informing providers of more cost-effective alternatives; Access to prescription records is increased and has been shown beneficial in drug recalls and natural disasters; Improved workflow at the pharmacy due to electronic delivery of the prescription reducing patient wait times; Assurance that the pharmacy received the prescription; and 8

Reduced handwritten forgeries. Documented problems related to e-prescribing include: Software design issues resulting in unclear or inaccurate prescriptions; Costs associated with the technology including start-up and maintenance; and Workflow disruption at the pharmacy due to bundled delivery of prescriptions. 1 As defined by the National Council for Prescription Drug Programs, e-prescribing comprises two functions: 1) Two way [electronic] communication between physicians and pharmacies involving new prescriptions, refill authorizations, change requests, cancellation of prescriptions, and prescription fill messages to track patient compliance; and 2) Potential for information sharing with other health care partners including eligibility and formulary information and medication history. 2 E-prescribing systems are a form of health information exchange that integrate prescribed medication data from multiple stakeholders; including pharmacy benefit managers (PBMs), payers, and pharmacies. Through these systems, medication histories are available for prescriptions that were brought to the pharmacy on paper or transmitted electronically. E-prescribing systems enable practitioners with authorized access to view medication history information at the point of care for coordination of patient drug therapy and improved quality of care. E-prescribing systems also provide practitioners with a secure means of electronically accessing health plan formulary and patient eligibility at the point of care. When physicians use e-prescribing systems to send prescriptions electronically, the prescriptions are transmitted through secure, private networks. The e-prescribing system transmits information through the use of encrypted telecommunication transmission channels that ensure secure, bidirectional, electronic connectivity between physician practices and pharmacies. Pharmacy networks connect pharmacies, physicians, and PBMs. The major pharmacy network in the United States is Surescripts, with more than 93 percent of all pharmacies in the United States certified to participate in the network. Another pharmacy network is Emdeon erx Network, performing more than seven billion health information exchanges per year. Both Surescripts and Emdeon erx Network collect and provide data to the Agency for the metrics displayed in this report. More information can be found about available e-prescribing products on the Surescripts (www.surescripts.com/) and Emdeon (www.emdeon.com) websites. 1.2. Electronic Prescribing Highlights in 2014 In 2014, the Centers for Medicare and Medicaid Services (CMS) continued making Medicare incentive payments for the meaningful use of certified electronic health records (EHRs) under the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. The HITECH Act provisions established meaningful use rules which include 1 Megan Ducker, Pharm D, Chelsea Sanchez, Pharm D, and Shawn Riser Taylor, Pharm D, Pros and Cons of E- Prescribing in Community Pharmacies, US Pharm. 2013; 8(38) (P&T supplement):4-7. 2 John Mack. "Ready or Not: Gearing Up for the Expansion of eprescribing." Pharma Marketing News, Vol. 3, #6. Retrieved from http://www.pharma-mkting.com/news/pmn36-article01.pdf in January, 2008. 9

electronic prescribing (e-prescribing) in the core set of required measures for eligible professionals to qualify for incentive payments. Surescripts continued to support the growth of e-prescribing in a number of ways including efforts to promote the e-prescribing of controlled substances, and providing national and state-level statistics on e-prescribing rates to assist stakeholders in measuring their progress. The Agency for Health Care Administration (Agency) continued making Medicaid incentive payments for the adoption of EHRs and for those providers achieving meaningful use of EHRs. The Agency directed the Florida Health Information Exchange (Florida HIE) to transition to a nationally accredited Direct Messaging service provider and began outreaching to pharmacies for participation in the Direct Messaging service of the Florida HIE. 1.3. Electronic Prescribing Metrics and Trends The Agency for Health Care Administration (Agency) has developed and published a set of indicators for tracking electronic prescribing (e-prescribing) adoption rates in Florida. Quarterly metrics are usually reported to the Agency by the end of April, July, October, and January from erx Emdeon and Surescripts. Surescripts reports a limited dataset to the Agency for the month ending each quarter. These metrics enable the Agency to gauge progress in Florida and in comparison with national rates. A key indicator is the e-prescribing rate which is the amount of e-prescribing relative to all prescriptions that could have been e-prescribed. The annual e-prescribing rate increased from 1.6% of Florida prescriptions in 2007 to 4.3% in 2008 to 14.4% in 2009 to 18.4% in 2010 to 27.1% in 2011 to 41.3% in 2012 and to 51.6% in 2013. Florida Quarterly E-Prescribing Metrics Previous Year Comparison 2013Q4 2014Q1 2014Q2 2014Q3 Month End of Qtr. E-Prescriptions 6,154,126 5,699,407 6,154,925 6,066,840 Month End of Qtr. E-Prescribers 32,306 33,074 34,252 31,183 Clear Active Licensed Prescribing Professionals Residing in FL Counties 3 85,225 86,826 87,982 85,881 Clear Active Licensed Prescribing MDs and DOs Residing in FL Counties 51,019 51,898 52,475 51,461 Increase in E-Prescriptions Compared to Prior Quarter: 1% -7% 8% 10.7% Month End of Quarter E-Prescribing Rate 4 : 54.4% 50.4% 54.5% 57.4% Average Monthly E-Prescriptions per E- Prescriber: 201 191 180 190 Increase in E-Prescribers Compared to Prior Quarter: 3% 3% 4% 4% Percent of Licensed Prescribing Professionals Who E-Prescribed: 38% 38% 39% 37% Percent of Licensed Prescribing MDs and DOs Who E-Prescribed: 63% 63% 65% 61% 3 Counts include all clear active licensed DN, MD, PA, ARNP, PO, and OS licensed professionals as obtained from the DOH s licensure database. 4 Based on est. 126,755,481 denominator/12 months for 2013 and 135,628,368 denominator /12 months for 2014 10

The average number of e-prescriptions per month increased from 372,085 in 2008 to 5,265,586 in 2013 and to 6,154,925 in the first nine months of 2014. If this trend continues at a consistent rate, reports through the end of 2014 are expected to show more than 6.3 million e-prescriptions being processed in Florida each month. Figure 1 represents the monthly average number of e- prescriptions since 2008 and the annual percent of increase. The projected annual percent of increase from 2013 to 2014 is 20%. Figure 1. Average Number of Electronic Prescriptions Per Month in 2008 to 2014 and Annual Increase The number of e-prescribers increased from 4,492 in December 2008 to 31,915 in 2013, and to 34,252 in September 2014. If this trend continues, the number of e-prescribers in Florida is projected to be over 35,000 by the end of 2014. Figure 2 represents the total number of e- prescribers since 2008 and the annual percent of increase. The projected annual percent of increase from 2013 to 2014 is 14%. Figure 2. Total Number of Electronic Prescribers per Month in 2008 to 2014 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2008 2009 2010 2011 2012 2013 2014 Projected Number of E-Prescribers 4,492 8,919 12,703 21,860 27,037 31,915 36,224 Increase 99% 42% 72% 24% 18% 14% 11

Based on the estimated annual monthly average of 13.3 million prescriptions per month, the estimated annual e-prescribing rate through September 2014 increased to 56.1 percent as compared to the annual e-prescribing rate of 51.6 percent in 2013. Figure 3 shows the increasing trend in the e-prescribing rate since 2008. Figure 3. Estimated Average Annual Electronic Prescribing Rate, 2008 to 2014 Figure 4 presents Florida s month end of quarter e-prescribing transactions as reported by Surescripts and Emdeon erx Network and e-prescribing rates. In September 2014, a total of 6,154,925 e-prescriptions were written, a one-and-half percent increase compared to December 2013, with 6,066,840 e-prescriptions. The totals correspond to the number of new e-prescriptions and refill e-prescriptions. The annual e-prescribing rate increased by almost five percent compared to 2013. Figure 4. Monthly Total Number of New and Refill Electronic Prescriptions in Florida and Electronic Prescribing Rates, January to September 2014 65,000 9,700,000 2014 YTD Electronic Prescribing Rate: 56.1% 9,200,000 60,000 8,700,000 55,000 8,200,000 Percent of all Prescriptions that were 50,000 E-Prescriptions, Monthly E-Prescribing Rate 7,700,000 7,200,000 45,000 6,700,000 40,000 54.4% 50.4% 54.5% 6,200,000 5,699,407 6,154,126 6,154,925 5,700,000 35,000 5,200,000 30,000 32,306 33,074 34,252 4,700,000 25,000 4,200,000 3,700,000 20,000 3,200,000 15,000 2,700,000 10,000 2,200,000 1,700,000 5,000 Mar 2014 Jun 2014 Sep 2014 1,200,000 Active Electronic Prescribers New and Refill E-Prescriptions 12

The below chart shows a comparison of the number of new e-prescriptions and refilled e- prescriptions at the end of the first, second, and third quarters of 2014. There were 6,154,126 total e-prescriptions at the end of March with 5,361,779 or 87 percent transmitted as new e-prescriptions and 686,509 or 13 percent transmitted as refilled e- prescriptions. By the end of September 2014 total e-prescriptions increased to 6,154,925 with 5,435,155 or 88 percent new e-prescriptions and 710,770 or 12 percent refilled e-prescriptions. Figure 5. Comparison of Electronic Prescribing Activity by New and Refill Authorized Electronic Prescriptions at End of Quarters in 2014 10,000,000 9,000,000 8,000,000 87% 88% 88% 100% 90% 80% 7,000,000 6,000,000 6,154,126 5,597,242 6,154,925 70% 60% 5,000,000 4,000,000 5,361,779 4,927,601 5,435,155 50% 40% 3,000,000 30% 2,000,000 20% 1,000,000 0 686,509 669,641 719,770 Mar 2014 Jun 2014 Sep 2014 Total E-Prescriptions (New and Refill Orders) New E-Prescriptions E-Prescription Refill Orders Percent of E-Prescriptions that were New 10% 0% 13

The number of Medicaid e-prescribing eligibility transactions and records found continued to grow during 2014 as did the number of patients. In January 2014 there were 1,395,397 transactions which increased by 15% to 1,604,958 in September 2014. For the same period, the number of patients increased by 9 percent and the number of prescribers increased by 41 percent. The data indicates that in 2014 prescribers issued a monthly average of 32 e-prescription eligibility transactions for a monthly average of 17 patients and received an 88 percent monthly average of eligible record returns. Figure 6. Florida Medicaid Program Electronic Prescribing Eligibility Transactions, Records Found, Patients and Prescribers, January 2014 through September 2014 1,800,000 1,600,000 1,391,720 1,408,194 1,253,679 1,395,397 1,400,000 1,319,850 1,244,3361,244,449 1,259,763 1,187,187 1,181,672 1,181,701 1,054,430 1,104,522 1,200,000 1,302,692 1,146,112 1,088,530 1,266,804 1,044,428 1,219,925 1,243,879 1,111,633 1,075,9381,134,631 1,111,214 1,116,329 1,000,000 937,901 1,057,086 1,137,835 1,048,773 918,333 952,100 800,000 865,030 600,000 400,000 1,604,958 1,470,559 1,376,7391,404,481 1,301,046 1,235,882 1,224,955 1,137,157 744,196 655,480 565,185 616,555 708,297 744,548 729,114 593,277 632,890 628,042 626,064 677,302 631,877 585,963 629,563 590,106 569,205 693,317 1,429,903 1,268,574 783,511 774,119 739,756 200,000 0 27,662 29,694 30,502 32,207 33,465 34,226 35,259 28,200 28,934 30,676 30,801 32,887 32,508 36,069 37,477 36,089 43,702 52,551 39,238 48,372 50,680 Eligibility Transactions Eligible Records Found Unique Patients Unique Prescribers Network activity comprises the cycle of e-prescribing, from requesting eligibility to ordering a prescription and authorizing a refill. 14

1.4 Survey of Florida Pharmacists on Electronic Prescribing In 2014, Florida International University (FIU) conducted a survey of Florida pharmacists about their participation in electronic prescribing (e-prescribing), their experience with e-prescribing, and the level of interest in other health information exchange services. The Florida Pharmacy Association (FPA) and Florida Association of Community Health Centers (FACHC) assisted with the survey, which was distributed online. Responses were received from 150 pharmacists associated with the FPA and 20 FACHC associated health center pharmacies. The majority of respondents associated with the FPA identified themselves as community pharmacists (54 percent) or reported that they were part of a corporate chain (31 percent). There was representation of rural pharmacies with 24 percent of pharmacists associated with the FPA indicating a rural setting, and 26 percent of health center respondents indicating that they were located in a rural setting. The survey found a high level of adoption, with 90 percent of the respondents reporting that they have an e-prescribing system as shown in Table 1. The majority of respondents reported more than ten e-prescriptions daily in the previous month (Table 2), and 41percent of respondents indicated more than 50 percent of health professionals used e-prescribing in their market area (Table 3). Table 1 E Prescribing System Available Response Count % Yes 190 90% No 21 10% Total 211 100% Table 2 E Prescriptions Received Prior Month Response Count % None 2 1% One to six each week 5 3% One to ten daily 24 14% More than ten daily 141 82% Total 172 100% 15

Table 3 Estimated Use of E Prescribing by Health Professionals in Market Area Response Count % Less than 10% 8 5% 10% but less than 25% 28 16% 25% but less than 50% 57 33% More than 50% 72 41% Not sure 9 5% Total 174 100% While many respondents indicated a preference for e-prescribing over traditional prescribing, with 61 percent of respondents preferring e-prescribing as displayed in Table 4, 25 percent preferred traditional prescribing. In addition, benefits in error detection were reported by a minority of respondents with 27 percent of respondents reporting that their e-prescribing system was effective in detecting errors (Table 5). Table 4 Satisfaction with E Prescribing Compared to Traditional Prescribing Response Count % e-prescribing 95 61% Traditional prescribing 39 25% Not sure 22 14% Total 156 100% Table 5 Rating of Level of Effectiveness of E Prescribing System in Detecting Errors Response Count % Very Ineffective 12 7% Ineffective 39 24% Neither Effective nor Ineffective 70 42% Effective 33 20% Very Effective 11 7% Total 165 100% 16

As shown in Table 6, electronic prescribing of controlled substances (EPCS) was not reported to occur routinely, with 64 percent of pharmacists indicating that none were received in the past week. These findings are consistent with a recent national study of EPCS trends which reported only one percent of all e-prescribers were enabled for EPCS as of December 2013. 5 The majority of pharmacist respondents did not indicate a high degree of concern about receiving e-prescriptions for controlled substance, although 17 percent were extremely concerned (Table 7). Table 6 E Prescriptions for Controlled Substances Received Prior Month Response Count % None 111 64% One to six each week 25 15% One to ten daily 18 10% More than ten daily 19 11% Total 173 100% Table 7 Level of Concern About E Prescribing of Controlled Substances Response Count % Extremely concerned 30 17% Moderately concerned 40 23% Somewhat concerned 40 23% Slightly concerned 28 16% Not at all concerned 35 20% Total 173 99% 5 Meghan Hufstader Gabriel, PhD; Yi Yang, MD, PhD; Varun Vaidya, PhD; and Tricia Lee Wilkins, PharmD, PhD - See more at: http://www.ajmc.com/publications/issue/2014/2014-11-vol20-sp/adoption-of-electronic-prescribing-forcontrolled-substances-among-providers-and-pharmacies/1 Adoption of Electronic Prescribing for Controlled Substances Among Providers and Pharmacies the American Journal of Managed Care (AJMC), November 17, 2014 (published online). 17

A lack of access to complete patient medication histories was reported by 74 percent of respondents, with respondents indicating that they do not have access to histories from unaffiliated pharmacies, as displayed in Table 8. Respondents agreed that having access to patients complete medical histories would be beneficial to the professional services provided by the pharmacy. Such access was thought beneficial by 91percent of respondents, as shown in Table 9. Table 8 Availability of Patient Medication Histories of Unaffiliated Pharmacies Response Count % Yes 37 22% No 127 74% Not sure 7 4% Total 171 100% Table 9 Level of Agreement that Complete Patient Medication History Access Beneficial Response Count % Strongly agree 92 55% Agree 60 36% Neither Agree nor Disagree 11 6% Disagree 2 1% Strongly Disagree 3 2% Total 168 100% 18

Section 2. Electronic Prescribing Adoption Activities 2.1. Florida Electronic Prescribing Clearinghouse Section 408.0611, Florida Statutes, was passed into law during the 2007 Legislative Session. It required the Agency for Health Care Administration (Agency) to create a clearinghouse of electronic prescribing (e-prescribing) information which was made available on the Agency s website in October 2007. The purpose of the Electronic Prescribing Clearinghouse is to report e- prescribing trends and provide information to promote the implementation of e-prescribing by health care practitioners, health care facilities, and pharmacies in an effort to prevent prescription drug abuse, improve patient safety, and reduce unnecessary prescriptions. The Florida Electronic Prescribing Clearinghouse can be accessed at: http://www.fhin.net/eprescribing/index.shtml. Information about products nationally certified for the Medicaid Electronic Health Record Incentive Program, including e-prescribing, can be found at the companion website, Medicaid Electronic Health Record Incentive Program. 2.2. Meaningful Use Incentives for Electronic Prescribing The federal Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) established incentives for certain Medicare and Medicaid providers related to the adoption and meaningful use of electronic health record (EHR) technologies. To qualify, an eligible professional must use certified EHR technology in a meaningful manner, demonstrate engagement in information exchange, and report clinical quality measures using certified EHR technology. Electronic prescribing (e-prescribing) is a requirement for eligible professionals to establish that the certified EHR technology is used in a meaningful manner. The meaningful use requirements for eligible professionals to receive Medicaid incentives after the first year of adoption are identical to the Medicare requirements. The Centers for Medicare and Medicaid Services (CMS) issued the final rules specifying the requirements for obtaining Medicare and Medicaid incentives related to the adoption and use of EHRs (i.e. Stage 1 Meaningful Use ) in July 2010. In the final rules, there is a core set of measures and a menu set, with 15 core measures for eligible professionals and 14 measures for hospitals. Providers must perform the core set and five additional measures selected from a menu set of measures to demonstrate meaningful use. 6 E-prescribing is one of the core set measures required of eligible professionals. Eligible professionals must achieve a 40 percent e-prescribing rate to qualify for an incentive payment under the program. These thresholds apply to all of the provider s patients, not limited to Medicaid and Medicare. Although e-prescribing is not a Stage 1 core requirement for hospitals, included in the core set are several measures related to medication management; including computerized physician order entry, drug-drug interaction checks, maintaining active medication lists, and maintaining active medication allergy lists that are required for hospitals and eligible professionals. 6 Department of Health and Human Services, Medicare and Medicaid Programs; Electronic Health Record Incentive Program, July 28, 2010. http://www.gpo.gov/fdsys/pkg/fr-2010-07-28/pdf/2010-17207.pdf 19

The menu set includes a measure for medication reconciliation applicable to hospitals or eligible professionals. CMS issued the final rules establishing the Stage 2 requirements for the meaningful use of EHRs August 23, 2012. The threshold rate was raised to a 50 percent e-prescribing rate for eligible professionals that must be met among other requirements to receive an incentive payment from Medicare or Medicaid. 7 Stage 2 Meaningful Use Requirements Related to Medication Use computerized prescriber order entry (CPOE) for medication orders directly entered by any licensed health care professional that can enter orders into the medical record per state, local, and professional guidelines (more than 60 percent); Enable and implement the functionality for drug-drug and drug allergy interaction checks for the entire EHR reporting period; Provide a summary of care record for more than 50 percent of transitions of care or referrals with 10 percent provided electronically; The eligible hospital or professional who receives a patient from another setting of care or provider of care, or believes an encounter is relevant, should perform medication reconciliation (more than 50 percent); In addition, eligible health care professionals must generate and transmit permissible prescriptions electronically (more than 50 percent of permissible prescriptions); There is one menu item from which eligible hospitals can choose that relate to medications; generate and transmit permissible discharge prescriptions electronically (more than 10 percent). In September 2011, the Agency for Health Care Administration (Agency) launched the Florida Medicaid Electronic Health Record Incentive Program. Eligible professionals and hospitals may register and apply for incentives associated with the adoption, implementation, or upgrade of a certified EHR system. Demonstration of meaningful use is not required to receive Medicaid incentive payments in a provider s first payment year. In subsequent payment years, eligible professionals may apply for additional incentives that require documentation of the meaningful use of a certified EHR including meeting the e-prescribing requirements of the program. As of November 7, 2014, Medicaid incentive payments had been made to 2,862 eligible professionals for meaningful use. 2.3. Medicare Incentives for Electronic Prescribing Beginning January 1, 2009, the federal Medicare Electronic Prescribing Incentive Program, as authorized under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), began offering incentive payments to eligible professionals who are successful electronic prescribers (e-prescribers) as defined by MIPPA. Successful e-prescribers were to receive a two 7 Department of Health and Human Services, Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 2, Thursday August 23, 2012. http://www.ofr.gov/(x(1)s(uzclbwrx5fwqm2w2mipkysrh))/ofrupload/ofrdata/2012-21050_pi.pdf 20

percent incentive payment for 2009 and 2010; a one percent incentive payment for 2011 and 2012; and a one-half percent incentive payment in 2013. 8 Eligible professionals who are not successful e-prescribers by 2012 are subject to a differential payment (penalty) beginning in 2012. The differential payment would result in the physician getting 99 percent of the total allowed charges of the eligible professional s physician fee schedule payments in 2012, 98.5 percent in 2013, and 98 percent in 2014. 9 Medicare is expected to save up to $156 million over the five-year course of the program in avoided adverse drug events. It is estimated that Medicare beneficiaries experience as many as 530,000 adverse drug events every year, due in part to negative interactions with other drugs, or a prescriber s lack of information about a patient s medication history. 10 On July 6, 2012, The Centers for Medicare and Medicaid Services (CMS) published proposed rules that would establish hardship exemptions from the Medicare e-prescribing differential payment penalty applicable to 2013 and 2014 if the eligible professional achieves meaningful use or registers and adopts certified EHR technology in the timeframes specified in the rule. The MIPPA penalty continues through 2014, after which Medicare meaningful use penalties begin. 2.4. Electronic Prescribing of Controlled Substances Until 2010, the U.S. Drug Enforcement Administration (DEA) regulations required that controlled substances be written on a paper prescription pad. On March 29, 2010, the DEA issued an interim final rule permitting electronic prescribing of controlled substances (EPCS). The rules specify system requirements related to identity proofing; access control; and auditing for prescribing practitioners and other registrants, electronic prescribing (e-prescribing) vendors, pharmacies and pharmacists, among others. In 2014, the Agency for Health Care Administration (Agency) worked with the Florida Pharmacy Association, the Board of Pharmacy, and other stakeholders to gain an understanding of Florida law related to EPCS in order to encourage the e-prescribing of controlled substances. More information about engaging in EPCS is available on the Surescripts website at: http://surescripts.com/docs/default-source/products-and-services/surescripts_eprescribing_controlled_substances.pdf. Surescripts changed the map of states regulation status to include Florida as allowing EPCS of Schedule II drugs. 2.5. Pharmacy e-health Information Technology Collaborative In September 2010, nine national pharmacy organizations launched the Pharmacy e-health Information Technology Collaborative. The collaborative will work toward the greater participation of pharmacists in health information exchange (HIE) and address opportunities for 8 Department of Health and Human Services. HHS Takes New Steps to Accelerate Adoption of Electronic Prescribing. Monday, July 21, 2008. 9 Department of Health and Human Services. Medicare s Practical Guide to the Electronic Prescribing (erx) Incentive Program. CMS Publication No. 11399. November 2008. Retrieved from http://www.cms.gov/partnerships/downloads/11399-p.pdf on January 5, 2009 10 Department of Health and Human Services. HHS Takes New Steps to Accelerate Adoption of Electronic Prescribing. Monday, July 21, 2008. 21

pharmacists to access and contribute to the patient specific information in electronic health records (EHRs). A key objective of the collaborative is to identify the minimum data set and functional EHR requirements for the delivery, documentation, and billing of pharmacist provided medication management services. Such requirements include access to key medical information such as laboratory data and bi-directional communication flow among all practitioners. The collaborative has prepared a roadmap for pharmacy health information technology (HIT) integration. The roadmap includes goals and objectives to be prioritized by stakeholders. Goals include integrating clinical data with e-prescribing information, including pharmacy services in HIE, and developing infrastructure that supports the pharmacists role as a health care provider. 11 During 2014 the Pharmacy HIT Collaborative submitted comments to the Office of the National Coordinator for Health Information Technology (ONC) in response to the proposed rule, Voluntary 2015 Edition Electronic Health Record (EHR) Certification Criteria; Interoperability Updates and Regulatory Improvements posted February 26, 2014 in the Federal Register. The Pharmacy HIT Collaborative and its member organizations are supportive of continued certification criteria and standards for HIT and EHR in achieving a positive effect on non-eligible pharmacist health care providers. 2.6. Electronic Prescribing Standards and Certification Bodies The federal Medicare Prescription Drug, Improvement, and Modernization Act (MMA) included a provision for the adoption and testing of specific technical standards for the data exchange transaction that Part D plans would use for electronic prescribing (e-prescribing). In 2009, the National Committee on Vital and Health Statistics recommended that the Centers for Medicare and Medicaid Services (CMS) support the National Council for Prescription Drug Programs (NCPDP) 12 13 SCRIPT 10.6 standard in its Medicare Part D e-prescribing initiative. The EHR certification final rule issued August 23, 2012, by the Office of the National Coordinator for Health Information Technology establishing standards, implementation specifications, and certification criteria for EHRs (2014 edition), requires use of National Council for Prescription Drug Programs (NCPDP) SCRIPT version 10.6 as the only content exchange standard for e- prescribing in the ambulatory and inpatient settings. The rule requires the capacity to use RxNorm, the vocabulary standard, specifically RxNorm concept unique identifiers (RXCUIs). 14 11 Pharmacy e-health Information Technology Collaborative, The Roadmap for Pharmacy Health Information Technology Integration in U.S. Health Care. http://www.pharmacyhit.org/ 12 Freidman, et. al. (2009), Interoperable Electronic Prescribing In the United States: A Progress Report. Health Aff March/April 2009 vol. 28 no. 2 393-403. http://content.healthaffairs.org/content/28/2/393.abstract 13 Department of Health and Human Services, National Committee on Vital and Health Statistics, July 10-11, 2009 Meeting Minutes. http://www.ncvhs.hhs.gov/090610mn.htm 14 Department of Health and Human Services. Health Information Technology: Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology, August 23, 2012.. http://www.ofr.gov/ofrupload/ofrdata/2012-20982_pi.pdf 22

2.7. Outreach to Pharmacies During 2014, the Agency transitioned to a new Direct Messaging service provider that is nationally accredited, enabling the service to connect for the exchange of messages among providers using other nationally accredited vendors. After the transition was completed in August 2014, the Agency developed outreach materials for health care providers and provider associations. The Agency will assist pharmacists and other providers interested in using Direct Messaging with information on costs and how to register for the service. Materials are posted on the Florida HIE website at: https://www.florida-hie.net/. 2.8. Health Information Exchange Coordinating Committee Section 408.0611, Florida Statutes, requires that the Agency for Health Care Administration (Agency) convene quarterly meetings of stakeholders from organizations that represent health care practitioners, health care facilities, pharmacies, organizations that operate electronic prescribing (eprescribing) networks, organizations that create e-prescribing, and regional health information organizations to assess and accelerate the implementation of e-prescribing. This legislation also requires the Agency to create the Electronic Prescribing Clearinghouse website. The Health Information Exchange Coordinating Committee (HIECC) was formed by the State Consumer Health Information and Policy Advisory Council (Advisory Council) to advise the Agency in implementing a strategy to establish privacy-protected, secure, and integrated exchange of electronic health records among physicians involved in patient care which includes the exchange of medication information through e-prescribing. The Agency assigned the HIECC the advisory role regarding e-prescribing promotional activities in 2010. A representative of the Florida Pharmacy Association was added to the membership of the HIECC and approved by the Advisory Council at its September 16, 2010, meeting. In 2010, the Advisory Council added measurable objectives to its goals for health information exchange (HIE) to facilitate integration of e-prescribing within HIE initiatives. The 2014 goal was to increase the e-prescribing rate to 60 percent statewide. The HIECC and Advisory Council continue to monitor progress in e-prescribing adoption and the Agency s strategies to promote e- prescribing. The HIECC held four meetings in 2014. 2.9. Action Steps In 2015, the Health Information Exchange Coordinating Committee (HIECC) and the Agency for Health Care Administration (Agency) will address the following action steps to further accelerate the adoption of electronic prescribing (e-prescribing) in Florida: 1) Continue to report e-prescribing metrics on a quarterly basis and include Florida Medicaid medication history statistics as available. The information will be posted on the Agency s website, www.fhin.net, as part of the Florida Electronic Prescribing Clearinghouse, and on the Agency s performance dashboard. 2) Promote e-prescribing adoption as an integral part of the education and outreach efforts for the adoption of electronic health records conducted under the Health Information Technology for 23

Economic and Clinical Health Act (HITECH) programs. These efforts will be coordinated through the leadership of the HIECC. 3) Engage the participation of state professional pharmacy associations and other stakeholders in promoting the e-prescribing of controlled substances consistent with applicable law. 4) Support emerging national standards for fully informed e-prescribing that require health plans and vendors to electronically transmit medication history and formulary and benefit information to e-prescribers and pharmacies. 5) Identify and promote opportunities for the participation of pharmacists in health information exchange (HIE) and work with pharmacists to identify HIE opportunities. 6) Continue to disseminate information on e-prescribing to the general public. The Agency will include e-prescribing information for consumers on the website, FloridaHealthFinder.gov. 24

Florida 2014 Electronic Prescribing Report 25

Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 1-850-412-3730 26